FOUR RECENT UNCONTAINED ENGINE FAILURE EVENTS PROMPT NTSB TO ISSUE URGENT SAFETY RECOMMENDATIONS TO FAA

The National Transportation Safety Board today issued two
urgent safety recommendations to the Federal Aviation
Administration (FAA). The first recommendation asks that the
FAA require operators of aircraft equipped with a particular
model engine to immediately perform blade borescope
inspections (BSI) of the high pressure turbine rotor at
specific intervals until the current turbine disk can be
redesigned and replaced with one that can withstand the
unbalance vibration forces from the high pressure rotor. The
second recommendation asks the FAA to require the engine
manufacturer to immediately redesign the disk. The NTSB
issued an additional recommendation for a requirement that
operators perform a second type of inspection and another
recommendation related to the engine manufacturer regarding
the installation of the replacement disk.

All four recommendations apply to the low pressure turbine
(LPT) stage 3 (S3) rotor disk in the General Electric (GE)
CF6-45/50 series turbofan engines that can fail unexpectedly
when excited by high-pressure (HP) rotor unbalance.

An uncontained engine event occurs when an engine failure
results in fragments of rotating engine parts penetrating
and exiting through the engine case. Uncontained turbine
engine disk failures within an aircraft engine present a
direct hazard to an airplane and its passengers because
high-energy disk fragments can penetrate the cabin or fuel
tanks, damage flight control surfaces, or sever flammable
fluid or hydraulic lines. Engine cases are not designed to
contain failed turbine disks. Instead, the risk of
uncontained disk failure is mitigated by designating disks
as safety-critical parts, defined as the parts of an engine
whose failure is likely to present a direct hazard to the
aircraft.

In its safety recommendations to the FAA, the NTSB cited
four foreign accidents, which the NTSB is either
investigating or participating in an investigation led by
another nation, in which the aircraft experienced an
uncontained engine failure of its GE CF6-45/50 series
engine.

The date, location, and circumstances of these four events
(none had injuries or fatalities) are as follows:

On July 4, 2008, a Saudi Arabian Airlines (Saudia) Boeing
747-300 experienced an engine failure during initial climb
after takeoff from Jeddah, Kingdom of Saudi Arabia. This
investigation has been delegated to the NTSB.

On March 26, 2009, an Arrow Cargo McDonnell Douglas DC-10F,
about 30 minutes after takeoff from Manaus, Brazil,
experienced loss of oil pressure in one engine. The pilots
shut down the engine and diverted to Medellin, Columbia.
This investigation has been delegated to the NTSB.

On December 17, 2009, a Jett8 Cargo Boeing 747-200F airplane
was passing through 7,000 feet above ground level (agl) when
the flight crewmembers heard a muffled explosion and
immediately applied left rudder. With one engine losing oil
pressure, the airplane returned to land at Changi,
Singapore. The NTSB is participating in the investigation
that is being led by the Air Accident Investigation Bureau
of Singapore.

On April 10, 2010, an ACT Cargo Airbus A300B4 experienced an
engine failure while accelerating for takeoff at Manama,
Bahrain. The crew declared an emergency, rejected the
takeoff, activated the fire suppression system, and
evacuated the airplane. The NTSB is participating in the
investigation that is being led by the Bahrain Ministry of
Transportation – Civil Aviation.

The four recommendations to the FAA are as follows:
1. Immediately require operators of CF6-45/50-powered
airplanes to perform high pressure turbine rotor blade
borescope inspections every 15 flight cycles until the
low pressure turbine stage 3 disk is replaced with a
redesigned disk that can withstand the unbalance
vibration forces from the high pressure rotor.
(Urgent)
2. Require operators of CF6-45/50-powered airplanes to
perform fluorescent penetrant inspections of CF6-45-
50- low pressure turbine stage 3 disks at every engine
shop visit until the low pressure turbine stage 3 disk
is replaced with a redesigned disk that can withstand
the unbalance vibration forces from the high pressure
rotor.
3. Immediately require General Electric Company to
redesign the CF6-45/50 low pressure turbine stage 3
disk so that it will not fail when exposed to high
pressure rotor unbalance forces. (Urgent)
4. Once General Electric Company has redesigned the CF6-
45/50 low pressure turbine (LPT) stage 3 disk in
accordance with Safety Recommendation [3], require all
operators of CF6-45/50-powered airplanes to install
the newly designed LPT S3 at the next maintenance
opportunity.

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    ALFONSO J. MONTANO APPOINTED NTSB ADMINISTRATIVE LAW JUDGE

    National Transportation Safety Board
    Washington, DC 20594

    FOR IMMEDIATE RELEASE: August 16, 2010
    SB-10-31

    Washington, DC – National Transportation Safety Board Chairman Deborah A.P. Hersman today announced the appointment of Alfonso J. Montano as an Administrative Law Judge for the agency.

    Judge Montano has been an Administrative Law Judge for 15 years with the Department of Health and Human Services and the Social Security Administration. During that time he heard adversarial cases dealing with Medicare nursing home compliance issues, fraudulent or abusive practices involving Social Security disability programs, and the exclusion or debarment of individuals or companies from participation in federal health care programs.

    Before becoming an Administrative Law Judge, Judge Montano served as a trial attorney for the U.S. Department of Justice.

    Judge Montano is a graduate of New Mexico Highlands University and earned his law degree at the University of San Francisco School of Law. He is a licensed private aircraft pilot.

    Judge Montano resides in Prince William County, Virginia with his wife. He has two adult children.

    Administrative Law Judges at the NTSB hear appeals from airmen, mechanics or companies that have had adverse action taken against their authority by the Federal Aviation Administration.

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  • NTSB TO OPEN DOCKET ON INVESTIGATION INTO THE CRASH OF A PILATUS AIRCRAFT IN MONTANA

    As part of its continuing investigation into a plane crash in Montana, the National Transportation Safety Board will open the public accident docket on Friday, December 3, 2010.

    On March 22, 2009, at 1430 mountain daylight time, a Pilatus PC-12/45, N128CM, crashed near the approach end of runway 33 at Bert Mooney Airport (BTM), Butte, Montana. The airplane was owned and operated by Eagle Cap Leasing of Enterprise, Oregon, as a personal flight under the provisions of 14 Code of Federal Regulations Part 91. All 14 people on board the airplane were killed in the accident. There were no ground injuries. The flight departed Oroville Municipal Airport, Oroville, California, at 1110 Pacific Daylight Time (1210 mountain daylight time) on an instrument flight rules flight plan and was destined for Gallatin Field, Bozeman, Montana. The airplane was diverting to Butte at the time of the accident. Visual meteorological conditions prevailed at the time of the accident.

    The information being released is factual in nature and does not provide analysis. The docket includes: investigative group factual reports, interview summaries, crew statements, air traffic control transcripts, controller statements, the meteorology report, and other documents.

    Additional material will continue to be added to the docket as it becomes available. Analysis of the accident, along with conclusions and a determination of probable cause, will come at a later date when the final report on the investigation is completed.

    The docket material will be made available at 10:00 am ET on December 3 on the NTSB website at http://www.ntsb.gov/dockets/foia_fri-dockets.htm#Aviation2010 in the FOIA electronic reading room. Details are listed by date.

    This will be a document release only. No interviews will be conducted.

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    NTSB REQUESTING COMMENTS ON PROPOSED PROCEDURAL RULES FOR AVIATION CERTIFICATE ENFORCEMENT CASE

    The NTSB has issued an Advance Notice of Proposed Rulemaking (ANPRM) seeking comments from the public regarding amendments to its procedural rules dealing with review of Federal Aviation Administration (FAA) certificate actions and its rules concerning applications for fees and expenses under the Equal Access to Justice Act.

    The NTSB listed three main reasons for its undertaking a review of 49 CFR parts 821 and 826: (1) to respond to parties’ suggestions for changing the rules; (2) to update rules that may be outdated; and (3) to modernize the rules to accommodate prospective electronic filing and document availability in case dockets.

    The ANPRM indicates that certain parties have approached the NTSB concerning emergency certificate actions, which involve cases in which the FAA issues an immediately effective order revoking or suspending a certificate. In such cases, the NTSB’s procedural rules allow a party to challenge the emergency status of the case, and provide an expedited timeline for doing so. The rules currently require the NTSB’s administrative law judges to “consider whether, based on the acts and omissions alleged in the Administrator’s order, and assuming the truth of such factual allegations, the Administrator’s emergency determination was appropriate under the circumstances.” The ANPRM invites public comments concerning this standard of review, as well as other aspects of the emergency review process, such as whether a hearing should occur to allow parties to provide evidence concerning whether the case should be treated as an emergency. The ANPRM further invites comments concerning whether parties should have an opportunity for another level of appeal to challenge the emergency status determination.

    In addition, the ANPRM also solicits comments concerning electronic filing of documents for aviation certificate cases, and requests specific consideration as to whether such electronic filing is feasible for individuals who opt not to retain an attorney. The ANPRM further seeks feedback concerning whether any outdated information exists in the current procedural rules.

    The 60-day comment period for the ANPRM concludes on February 22, 2011. The ANPRM may be accessed at the following link: http://origin.www.gpo.gov/fdsys/pkg/FR-2010-12-22/pdf/2010-32056.pdf.

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    NTSB PRESS RELEASE: NTSB CITES LACK OF BIRD STRIKE RESISTANT WINDSHIELD REQUIREMENTS IN FATAL CRASH OF HELICOPTER IN LOUISIANA

    National Transportation Safety Board
    Washington, DC 20594

    FOR IMMEDIATE RELEASE: November 24, 2010
    SB-10-45

    The National Transportation Safety Board today released a
    final report on a fatal crash involving a transport-category
    helicopter caused by a bird strike. The Board said the lack
    of requirements for bird strike-resistant windshields
    contributed to the crash, and called on the FAA to develop
    such requirements.

    On January 4, 2009, a dual-engine Sikorsky S-76C++
    helicopter (N748P), registered to and operated by PHI, Inc.,
    crashed into marshy terrain near Morgan City, Louisiana
    approximately 7 minutes after takeoff from Amelie,
    Louisiana, on a charter flight to an oil rig in the Gulf of
    Mexico. Both pilots and 6 of the 7 passengers were killed
    in the crash.

    The aircraft had reached level cruise flight at 850 feet
    mean sea level and 135 knots when the cockpit voice recorder
    recorded a loud bang, followed by sounds consistent with
    rushing wind and a power reduction on both engines. The
    aircraft crashed several seconds later. Feathers and other
    bird debris were collected from the canopy and windshield of
    the aircraft. Laboratory analysis identified the remains as
    coming from a female red-tailed hawk; the average weight of
    such a bird is 2.4 pounds.

    The investigation revealed that the impact of the bird on
    the canopy just above the windshield near the engine control
    quadrant likely jarred the fire extinguisher T-handles out
    of their detents and moved them aft, pushing both engine
    control levers into or near the flight idle position,
    reducing fuel to both engines. The pilots were probably
    disoriented from the broken windshield and rushing air and
    were unable to react in time to maintain control of the
    helicopter.

    The helicopter was originally equipped with laminated glass
    windshields that complied with European bird-strike
    resistance standards. PHI replaced the windshields with
    lighter-weight, aftermarket cast acrylic windshields that
    did not have any bird-strike resistance standards.

    The NTSB determined that the helicopter crashed because of
    the sudden loss of power to both engines following the bird
    strike and the subsequent disorientation of the crewmembers.
    Contributing to the accident, the Board said, were the lack
    of FAA regulations and guidance requiring helicopter
    windshields to be resistant to bird strikes, the lack of
    protections that would prevent the T-handles from
    inadvertently dislodging out of their detents, and the lack
    of a master warning light and audible system to alert the
    flight crew of a low-rotor speed condition.

    Recommendations were issued to the FAA dealing with, among
    other things, the design of S-76C++ fire extinguisher T-
    handles and engine control quadrants, and similar designs of
    other helicopters, and of audible low-rotor alarm systems;
    certification standards for helicopter windshields; and
    simultaneous dual-engine power loss training for helicopter
    pilots.

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    NTSB INVESTIGATING NEAR MIDAIR COLLISION

    National Transportation Safety Board
    Washington, DC 20594

    September 23, 2010

    NTSB INVESTIGATING NEAR MIDAIR COLLISION OVER MINNEAPOLISINVOLVING COMMERCIAL JETLINER AND SMALL CARGO AIRCRAFT

    The National Transportation Safety Board is investigating a near midair collision between a commercial jetliner and a small cargo aircraft that came within an estimated 50 to 100 feet of colliding near the Minneapolis-St. Paul Airport (MSP).

    On September 16, 2010, about 6:49 a.m. CDT, US Airways flight 1848 (AWE 1848), an Airbus 320, was cleared for takeoff on runway 30R en route to Philadelphia, Pennsylvania, carrying five crewmembers and 90 passengers. At the same time, Bemidji Aviation Services flight 46 (BMJ46), a Beech 99 cargo flight with only the pilot aboard, was cleared for takeoff on runway 30L en route to La Crosse, Wisconsin. Weather conditions at the time were reported as a 900-foot ceiling and 10 miles visibility below the clouds.

    Immediately after departure, the tower instructed the US Airways crew to turn left and head west, causing the flight to cross paths with the cargo aircraft approximately one- half mile past the end of runway 30L. Neither pilot saw the
    other aircraft because they were in the clouds, although the captain of the US Airways flight reported hearing the Beech 99 pass nearby. Estimates based on recorded radar data indicate that the two aircraft had 50 to 100 feet of vertical separation as they passed each other approximately 1500 feet above the ground.

    The US Airways aircraft was equipped with a Traffic Alert and Collision Avoidance System (TCAS) that issued climb instructions to the crew to avert collision. The Beech 99 was not equipped with TCAS and the pilot was unaware of the proximity of the Airbus. There were no reports of damage or injuries as a result of the incident.

    NTSB and FAA investigators conducted a preliminary investigation at the Minneapolis airport traffic control tower on September 18th and 19th and are continuing to review the circumstances of this incident.

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    NTSB INVESTIGATING OPERATIONAL ERROR NEAR NEW YORK

    National Transportation Safety Board
    Washington, DC 20594

    February 4, 2011

    The National Transportation Safety Board has been investigating an operational error that occurred near New York City in January.

    The Safety Board was notified of a Traffic Collision and Alerting System (TCAS) resolution advisory that occurred due to a near midair collision involving American Airlines flight 951 on January 20, 2011, at about 10:30 p.m. EasternStandard Time. The American Airlines aircraft, a Boeing777-200 (N7CA), had taken off from John F. Kennedy International Airport en route to Sao Paulo, Brazil and wasflying southeast. A flight of two U.S. Air Force C-17s was heading northwest toward McGuire Air Force Base, New Jersey. There were no injuries in the incident.

    The NTSB has interviewed air traffic controllers on duty at the time of the incident, and is gathering information from American Airlines and the Air Force.

    The air traffic controllers talking to each of the aircraft received conflict alerts, and immediately provided traffic advisories and turned their aircraft to resolve the conflict. In addition, the American Airlines crew responded to directions provided by TCAS. Radar data indicate that the aircraft came within a mile of each other at their closest point. The incident occurred about 80 miles southeast of New York City.

    Betty Koschig has been designated the NTSB’s Investigator-in-Charge for this incident. Further information will be released as it becomes available.

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